Big Bad Legacy EHR Products

IBM "cloud" computing - circa 1975

There is no self-respecting innovator in Health Information Technology (HIT) who has not spoken or written about the horrific state of Legacy EHR products, which are slowly but surely being deployed in more and more health care facilities as a result of Meaningful Use incentives and changing reimbursement models. A couple of months ago I saw an EMR in a small practice. They’ve been using it for 15 years and it was a DOS based system with the ubiquitous neon green text glaring on a black and sometimes blue background. Aha! That must be a Legacy EMR, and sure enough the doctor was looking to replace it with a more modern product, but which one should he get now? After all, the last thing you’d want is to have him buy yet another Legacy EMR.

According to dictionary.com, a Legacy system is a “computer system or application program which continues to be used because of the cost of replacing or redesigning it and often despite its poor competitiveness and compatibility with modern equivalents. The implication is that the system is large, monolithic and difficult to modify”.  Well that little DOS EMR was anything but large and monolithic, but nobody was going to invest a penny in redesigning it, and competitiveness wasn’t a term that came to mind when you looked at it, and replacing it is sure going to be an expensive proposition. The DOS EMR is definitely out then. The only question remaining is what it should be replaced with. Which EMRs in the marketplace should be avoided since they are truly Legacy EMRs sold under false premises to unsuspecting buyers? Well, it depends on who you ask.

You could separate the various EHR constituencies based on programming technology (e.g. MUMPS vs. .NET), based on promotional labels (e.g. Cloud hype vs. everything else), based on software architecture (e.g. integrated vs. modular), and a host of other technical criteria, most of which are overlapping to various degrees. A much clearer and natural separation occurs if you divide Health Information Technology (HIT) companies into two groups: those who have lots of customers and those who don’t. According to the latter, the former are all peddling Legacy systems. It seems that a veritable tsunami of innovation is building up outside the infamous walled gardens of existing, Legacy EHR vendors, threatening to bring those walls down any minute now.

As with any worthwhile technology innovators, the newcomers to the EHR marketplace have brilliant Silicon Valley pedigrees and beautiful Web 2.0 style websites, along with iPhone/iPad/Android native (i.e. client/server proprietary) apps to complement, or even supersede, the web offering. Actually using an “old fashioned” computer or laptop is starting to feel a bit Legacy in and of itself. The innovative products themselves can be divided into two categories as well: full-fledged EHRs and a variety of self-contained pieces, or modules, of what is currently considered a complete EHR. [Note: I am not including products like athenahealth here, since they are not new, do have a respectable customer base, and had no disruptive effects on the rest of the market.]

The innovative new EHRs are all Cloud-based, intuitive and easy to use, built from scratch by user-centered designers, and are offered at a fraction of current prices, or so the ads say. These are the Southwest Airlines of health care, coming in below market pricing, with bare-bones, friendly solutions for the non-customer segment and they have two insurmountable problems. First, almost none of them are actually below market price, which in the ambulatory sector stands now at about $500 per provider/per month for a fully loaded, gold-standard integrated EHR and practice management solution. This is an extremely difficult number to beat. Second, even a bare-bones solution should have all the bones. My guess is that Southwest Airlines would not exist today if their first flight service consisted of boarding passengers in Houston and then proceeding to cheerfully shove them out of the aircraft 150 miles outside of Dallas, expecting them to arrange for their own transportation into the city. And yet, this seems to be the preferred model of our innovative HIT products, and as ePocrates (a household name in health care), painfully discovered, there are no customers lining up for this type of experience no matter how innovative it is touted to be.

In the meantime the Legacy EHR market seems to be thriving, and no, the recent Allscripts misfortune (or mismanagement) is not an indication of an impending disaster any more than this year’s snowfall in Texas is a sign of global cooling. The reason for this seemingly inexplicable prosperity is threefold: a) the government is subsidizing EHR purchase b) there are no viable alternatives to existing products c) innovation is occurring within the established market leaders. Let’s look for example at one of the more popular ambulatory EHRs, which shall remain unnamed. A few short years ago, the product consisted of a basic integrated EMR/practice management system, with very few bells and whistles and lots of bugs. Today, the product comes with a solid Patient Portal with iPhone apps for patients, a full featured disease registry, an iPad version, natural language processing, disconnected mode operations, peer-to-peer communications, and of course a much improved EHR and all sorts of other features and modules. I don’t know about other folks, but somehow this does not seem like a Legacy product to me, and there are a few more just like this one. There may be Legacy products out there, but today’s top selling EHRs do not fit the description.

A very unfortunate side effect of the forced march to HIT innovation is the confusion created by the constant barrage of misleading statements from the various Southwest Airlines wannabes. I sometimes wonder if these new folks have ever seen an EHR, let alone use one or participate in building one. A quality EHR is much more than a handful of rudimentary web pages allowing patients to communicate with providers, no matter how loud and trendy the consumer movement is. A modular architecture is much more than a collection of disparate bits of software interfaced together with duct tape, no matter how standardized the duct tape is. There is a reason why the new iEHR for the VA and DoD was allocated $4 Billion for development over five to six years. There is a reason why it took Kaiser about the same amount of time and money to take Epic from its original state to the powerhouse product it is today. There is no room for Southwest Airlines type of innovation in an industry where the routes, the meals, the fuel and the seating arrangements are regulated by the Federal Government. Innovation is coming and will continue to come from within the established systems, NASA style.

So if you are still looking to replace that little DOS EMR, or an aging and no longer supported practice management system, find a good size EHR vendor, with a hefty customer base, who develops its software in-house, instead of randomly buying shiny things, and hitch your wagon to theirs. It will not be a perfect ride because there are no perfect rides, but it will get you where you need to be. There are no miracles, there will be no miracles, and every day you waste looking for one, will make it harder to catch up, because whether we like it or not, whether it is a smart thing or not, health care is moving up the IT escalator at a very brisk pace. It’s too late for partial, gradual or “lite” solutions. The time for dabbling with a little electronic prescribing and a little email, has long since passed. You’re either all in, or all out, and your patients desperately need you to be all in.

Hypothetical: Tofu at the Broccoli Court

The year is 2018 and President Tofu is fortunate to have a majority in both houses of Congress. America elected President Tofu when it became weary of partisan politics and developed a taste for a President with no preconceived notions and fully capable of absorbing the flavors of whatever surrounds him at the moment; a pragmatic, businesslike President for tough and fast-changing times. American small businesses are still hurting from the lingering effects of the Great Recession, but its larger bastions of business savvy are thriving in a booming global economy bringing cheap products to the impoverished masses armed with $5 cell phones, $10 netbooks and empowered by a Khan universal education system (the other Khan, not Genghis).

Many Americans are also benefiting from this expansion in some ways. For example, after the 2016 passage of the historical and liberating Student Protection and Affordable Education Act (SPAEA), many parents decided to take advantage of the Khan system, now owned and selflessly maintained by Google, and use the Government Education Voucher (GEV, pronounced give), minus the $15 for a cell phone and netbook for each child, to pay for the mandated health insurance penalty of 2010, thus breaking even on child mandates. This trend caught on like wildfire after some knucklehead libertarian tweet went viral on every social media outlet practically overnight, as a suggested measure to counteract the Constitutional, but still unpopular individual mandate to buy health insurance.

America’s Health Insurance Plans (AHIP) did not take very kindly to this popular trend, since most folks buying health insurance from US Health were now either elderly or sick. It should be noted that the other three health insurance providers, Liberty Health which insures elected public servants, Glamour Health which insures most sports and entertainment personalities and the Health Division of Goldman Sachs which provides discrete insurance to industry captains, were not affected by this phenomena, limited to some sectors of the currently or previously wage earning class. Most workers though, were provided health insurance through self-funded multi-national employers, as part of their wages. Unlike the misguided Liberal government of Mexico, who struck down in 2012 an early attempt by Walmart to pay their Mexican employees with store vouchers, the pragmatic administration of President Tofu, welcomed the business oriented solution of paying American workers with vouchers for the company health insurance store.

Seeing how by definition President Tofu found himself in close proximity to US Health executives, some since early childhood, he absorbed the pain and suffering caused to this worthy corporate citizen and decided that something must be done to ensure that elderly and sick Americans can afford US Health premiums and Khan Academy freeloaders don’t dump their health care costs on the rest of society. There were several options for President Tofu and his administration. He could have mandated that GEV should be spent at one of the few private prep schools, but that would impose undue burden on those brilliantly elite institutions of education, who were also very close to President Tofu’s heart. He could have mandated that all Americans not otherwise covered by health insurance, must purchase insurance from US Health at the ongoing premium rates, but some lesser representatives in his Party were deeply concerned with backlash from voters in the upcoming midterm elections, and President Tofu as close as he was with his colleagues, immediately absorbed their pain as well. Luckily there was another way out of this impasse.

In the summer of 2018, the landmark Life Protection and Perpetual Health Act (LPPHA) was passed in both houses with crushing bi-partisan support, and signed by the ever smiling President Tofu into law. Americans were very happy with this legislation, since all media outlets were running headlines informing the people that Congress in its wisdom is now guaranteeing health and long life for every American by 2020. For the skeptical 2012 audience, no, President Tofu was not miraculously transformed into a futuristic Indiana Jones marching out of the crumbling ancient temple with the magic challis in his raised hands, but science, particularly statistical analytics, has advanced to new heights in 2018, partially fueled by Khan Academy graduates.

A RAND corporation study conducted in December 2017, at the behest of a global retail industry giant, clearly showed that Americans employed by multi-national corporations are healthier and projected to have a much longer quality adjusted life expectancy than their peers who were not paid with company store vouchers. After careful adjustments of all measures designed to infer worker health status from corporate economic indicators, RAND concluded that multi-national workers and their dependents have a whopping 92 quality adjusted life years expectancy, thus leaving all OECD Socialized medicine countries in the dust. Other than using innovative study measures, clearly the multi-national corporations have identified the secret sauce to long life and perpetual health. In a follow-up study commissioned by AHIP, RAND identified the preventive health measures taken by self-funded employers as the indisputable cause for the longevity and excellent health of their charges.

Thus the LPPHA contained several provisions to spread the health amongst the rest of the Nation, which would dramatically reduce US Health costs and significantly contain taxpayer expenses for those who chose the 2012 penalty over buying health insurance. At the heart of the LPPHA (or PHA, pronounced phe or F), was a mandate for all citizens to purchase body weight, physical activity and happiness monitors, sold and administered by the corporation insuring their health. Since, most citizens insured by multi-nationals were already purchasing those monitors at the company store, as required by their employer, and since workers’ poor health clearly affects Commerce, and since all Commerce now is at least interstate Commerce, this seemed to be a very logical provision and its benefits to the millions of sedentary, overweight and demoralized Americans were self-evident. Hence the monitoring mandate gained enormous public support, according to the media. Of course, the Government would provide subsidies to those who cannot afford to pay for their own monitors, and monitors would be free to households under 200% FPL, which is really most of the unmonitored citizenry. In order to uphold the monitoring mandate a clever penalty will be imposed, modeled after the large employer health insurance rules, where people with a larger than the approved Body Mass Index (BMI), and/or a smaller than indicated daily activity level, and/or larger than normal depression quotient (as defined by the U.S. Preventive Services Task Force), would have to pay a penalty proportional to their income levels. Exceptions and voluntary drug treatment options are available for all categories.

For a fleeting moment after the beautiful ceremony of the LPPHA signing, by an obviously trim, fit and happy President Tofu, there were some thoughts in some old Liberal quarters that perhaps the LPPHA is unconstitutional and should be challenged in Court, but apprehensions died down quickly after experts read the 4562 pages of the statute and found that the Federal Government is not forcing us to buy broccoli. And America lived happily ever after. The End.

The People’s Advocate at the Supreme Court Bar

H. Bartow Farr, III, Esq.

The Patient Protection and Affordable Care Act (PPACA) has finally met its challengers in the highest Court in the land and following the three days showdown, there’s nothing left but watchful waiting for the Supreme Court to hand down its final decision. All media outlets from left, right and supposedly middle are covering the events and hundreds of experts are ready to make predictions based on the inflections in one Justice’s voice. I made a point to not read any of that, and if you are an informed citizen who still insists on making his/her own mind, the very impartial SCOTUS blog is the place to go for links to the audio and transcripts of all oral arguments and all briefs submitted to the Court. By this logic you should probably not read what follows below either, but if you do, this is an unorthodox (neither left nor right) look at the proceedings from a citizen's point of view, a perspective that struck me as lacking in the proceedings themselves.

The main contenders were the Republican Governments of 26 States against a Federal Government controlled by a Democratic administration. There were also some private plaintiffs with a strong Libertarian argument, but their contribution to the subject is not clear to me, and is probably just a largely inconsequential sideshow. Generally speaking local governments were wrestling with central government in an outdated Federalist argument, where the people themselves have no standing.

The main event took place on Tuesday, March 27, where the constitutionality of the individual mandate, requiring every American to buy health insurance or pay a penalty, was argued, with the Federal Government arguing that its power to regulate interstate commerce includes the right to mandate that everybody buys health insurance, and if not, then the penalty should be viewed as a tax. The State Governments argued as expected that this gives the Feds unlimited power and a penalty is not a tax. The lively debate came complete with broccoli, burial insurance and babies being denied care at the hospital, hypotheticals. But here is what I found interesting: at the heart of the Federal Government argument was the contention that the uninsured are basically offloading their health care costs on the insured and society in general, therefore we must mandate that they buy insurance and pay their fair share. The States on the other hand, argued that forcing healthy people who don’t want to buy insurance to subsidize the sick is really not fair. Most Americans, as everybody agreed, are already purchasing health insurance, so who are these freeloading uninsured?

Well, it seems that 68% of the uninsured are under 140% of the Federal Poverty Level (FPL), and 95% of them are below 400% FPL. A full 45% of poor adults and 17% of poor children (under 100% FPL) are uninsured. Are these our freeloaders? Are these our interstate frequent travelers who impose huge uncompensated expenses on States where they don’t live? Are these poor people without insurance seeking out States that enacted guaranteed-issue and community rating insurance laws and move there en-masse? Is anybody else doing that? Do we even know what problem we are trying to solve?

Another pearl from the March 27 arguments was the realization that the States concede that the Federal Government has the power to require that people pay for health care with insurance. They only differ on the timing of buying the necessary insurance instrument, with the State Governments insisting that a free citizenry should have the right to purchase insurance en route to the ER, if they so choose, and the Feds arguing that they must buy insurance the day they are born. Does that mean that one cannot pay for health care with cash, or chickens? Will they check to see if you have insurance and if so, cash payments will be disallowed? What do you do if you’re one of the penalized? Do you get to pay cash, or do you get some services in return for all those penalties you paid into the system?

As interesting as the constitutionality arguments were, I found the session on severability to be most enlightening. On Wednesday, March 28, the Court grappled with the next steps, if the individual mandate is by any chance found to be an unprecedented and unlimited expansion of Congress powers and thus ruled unconstitutional. The 26 Republican governed States argued that the Court should throw out the entire Obamacare legislation with the mandate, because everything else in the PPACA is either hinging on the offending mandate or is unimportant. This is not surprising, since the war on the individual mandate, which is the brainchild of an ultraconservative foundation, is just a battle in a much larger war to remove the current Democratic President from office. The Federal Government began its arguments by mentioning the millions of citizens that are not standing before the Court and how the Court should nevertheless give them consideration. That was beautiful, but it didn’t last long, because eventually it became clear that the Federal Government is asking the Court to strike down both guaranteed-issue and community rating clauses along with the individual mandate, if found unconstitutional.

The Federal Government, true to form, was arguing on behalf of its insurance companies patrons. Unless the Feds can guarantee a certain number of customers, there is no way that insurers will agree to sell their wares in a non-discriminatory manner, because discrimination is how insurers make money, and no government should infringe upon basic rights of corporations. It fell to an attorney independently appointed by the Supreme Court to argue for the people, and (very eloquently) make the simple point that the purpose of the PPACA was not to provide customers to insurers, but to make health care affordable to all Americans, including poor and sick ones. The individual mandate is just one tool in an arsenal of tools to accomplish that end. It may be a very useful tool, but it’s not the only tool, and therefore if it is found unacceptable, it should be severed from the legislation and removed without throwing out the baby with the bathwater.

So the People finally got their 15 minutes in Court, represented by Court appointed counsel, as paupers usually are. Whatever the Court decides in this case, I will forever be grateful to the Supreme Court of the United States, the nine unelected Justices, who saw fit to solicit someone to speak for the People, something that neither States nor Federal Governments seemed to be too terribly inclined to do. And I am grateful that the Court chose H. Bartow Farr, III, Esq. to represent us in this matter, since his oral arguments were second to none, and may God grant the Court the wisdom to do what Mr. Farr advocated that they do, and the People shall prevail.

I Don’t Want To Be Digitized

I live in a bubble where everybody seems to be obsessed with Health Information Technology (HIT). The average man or woman you meet on any American street has no idea and no concern about the insurmountable difficulties associated with Electronic Health Records (EHR) and other HIT initiatives. I know because I asked random folks I encounter at the gas station, the dry cleaners, the supermarket, Starbucks, the grocery store and other mundane locations. It’s not a scientific survey, but it is disconcerting for me to realize that my days are consumed by something nobody cares about. I’d like to think that, although obscure, my endeavor could somehow better the condition of human kind, at least the portion of human kind that I can touch. To that end I come up with visions of a future where HIT enables millions of people to receive state of the art, truly personalized health care in thousands of small intimate locations filled with expertise and compassion, where everybody knows your name, and the computer knows your genome. Other folks in my bubble, probably for the same reason, are conjuring futuristic images of implantable sensors and long distance care delivered by artificial intelligence, with the occasional, and mostly preventable, acute episode addressed by robotic devices, supported by super computers in an operating room of the future.

Steve Jobs was an implementer. Gene Roddenberry was a visionary. There isn’t much technology out there today that was not envisioned by Mr. Roddenberry in his sci-fi odyssey through the infinite universe, and the most forward thinking idea tossed around now is Gene Roddenberry’s half century old notion of a tricorder, a hand held device that can evaluate health and diagnose disease in noninvasive ways. The Star Trek ethos presumes the existence of EHRs and HIT, just like it presumes the availability of all information ever recorded (Big Data?) in the all-powerful computer that speaks with Mrs. Roddenberry’s voice. We have a long way to go before the technology vision is fulfilled, but we have an even longer trek ahead of us before Earth becomes the hunger free, poverty free, greed free, egalitarian planetary bliss, where Mr. Roddenberry envisioned his technology to be operating for the common good.

The other day I was watching a recording of Dr. Eric Topol speaking to a group of Google engineers. The charismatic and super credentialed Dr. Topol has a new book out, and a vision of digitizing human beings in order to prevent and cure disease. Humanity has been engaged in a quest to prevent and cure disease since the dawn of civilization, and probably long before that. While the means to that end have steadily advanced from a patriarch blessing, to magic bracelets, secret potions and finally to chemicals and HIT, the goal remains the same: we don’t want to suffer and we don’t want to die, unless we choose to do so for a higher cause. While the word of God was usually identified as that higher cause, individual Liberty is the modern day call to arms, considered to be worth both suffering and death, but this too may change, because what is now mockingly referred to as “rugged individualism” is quickly giving way to consumers neatly aggregated in analytic hives of predictive similarity.

In the course of his Google presentation, Dr. Topol displayed a variety of cool technologies coming closer and closer to Gene Roddenberry’s tricorder, some that are already available to use and others still lurking in research labs. My fellow residents of the HIT bubble have probably heard of most of these iPhone enabled little miracles allowing one to turn his mobile phone into an ambulatory Intensive Care Unit to constantly monitor vital signs, activity, sleep patterns, items ingested and items excreted. Still in the making are widgets that can monitor your brain waves, your thoughts and other implantables capable of predicting disease before it actually manifests. A broad new horizon is opening up for Ari, an old friend of mine, who is a diagnosed hypochondriac, and until now was costing the socialized health care system in his country tens of thousands of dollars every year for EKGs alone, sometimes in the ER, and most of the time in an endless string of cardiology appointments.

In order for these things to be useful to more folks than just my old friend, they must be somehow tethered to a central command center, where the data is continuously analyzed and either the malfunctioning unit is warned of impending disaster, or better yet, actions are triggered to address the malfunction and restore the unit to normal operating parameters, based on individualized genomic data, other environmental and historical factors, and similar data points from millions of other humans. Obviously, engaging in such complex research and analytics requires that all monitoring data of all people is aggregated and considered by as many intellects as possible, which would be all of us in a sweeping wave of democratization of science placing the infallible wisdom of the collective above the fallible wisdom of any one individual. This is above and beyond Roddenberry’s wildest dreams. Or is it?

I’m afraid (truly afraid) that the glory must once again go to Gene Roddenberry and his crew. Although it took them a bit longer than the tricorder, they composed a detailed picture of a future where humanoids are outfitted with monitoring devices from birth and where crowdsourcing is the prevailing mechanism for collective governance and operations. They named those fictional people The Borg.

Where is Health Care’s Big Data?

The world of health care is abuzz with heated discussions about health information exchange, data liberation and the beneficial consequences of these actions to all stakeholders who use, deliver, regulate or profit from the one fifth of the U.S. economy devoted to medical care. While the efforts to liquefy health information from its solid paper state to a fluid stream of zeros and ones are hardly new, the release of the Meaningful Use Stage 2 proposed rules, has triggered a renewed Pavlovian response to the prospect of having people’s health information flowing freely over the Internet creating massive amounts of Big Data. Before the frenzy gets way ahead of itself, perhaps we should take a closer look at how health information is created, where it resides, how it is shared and what Meaningful Use Stage 2 is targeting for change. In short, let’s follow the Data…

Health Care Data Creation
Health information about an individual begins accumulating from the moment of birth, which is duly recorded when a tiny new consumer emerges into the world. Over one’s life, encounters with the medical system are carefully recorded and now, most of those encounters will be computerized. The following are the main sources of health data:

• Medical Care Providers – Hospitals, physicians, pharmacists, nurses, therapists and eventually long term care facilities are recording medical encounter information both for treatment and for financial purposes. The data created by health care providers is very rich in clinical information and also contains a significant amount of socio-economic details. Currently, medical information is scattered amongst all providers of health care encountered during a lifetime, and is mostly maintained on paper. Portions of it may or may not be exchanged in an ad-hoc fashion when people seek care at various medical facilities.
• Public and Private Payers – For the overwhelming majority of Americans who utilize insurance instruments to finance medical care, a lower fidelity version of health information is being maintained by the payer, mostly in electronic format, tallying ailments, therapies and everything else that has a dollar value associated with it.
• Ancillary Providers – From pharmacies to laboratories and imaging facilities, ancillary service providers are also maintaining lists of medical services and products provided to people and when pertinent, clinical results and invoicing information. This information is also largely maintained in electronic format.
• Personal Health – Although largely confined to a tiny minority of healthy, educated and tech savvy people, the results of personal monitoring of health indicators are beginning to accumulate in various private information systems. Currently most of this data is created by individuals outside the traditional medical system and is maintained and controlled by new and rather small technology vendors in electronic format.

Health Care Data Whereabouts
Obviously entities that create health data are also maintaining complete copies of said data for their records. However, large amounts of data are being exchanged currently between facilities of care, payers, diagnostic companies and government agencies, mostly in electronic format. As data moves around, and it does move, new repositories of data also emerge.

• Health Data Creators – Medical care providers, ancillary services providers and payers of all stripes store, maintain and supposedly own practically all health data created by their various business units and all copies of data created by others and transmitted to them during the course of business. There are significant overlaps between various data creators. For example, while payers do create financial data, all clinical information they possess is created and also stored by others.
• Public Health Agencies – Registries (e.g. immunizations, cancer, etc.) and other regulatory reporting repositories are also storing pieces of information transmitted to them by health data creators as required by State laws and vary greatly in availability and capabilities, but most information is electronically maintained.
• Clearinghouses – The facilitators of information exchange, mostly medical claims and payment data, medications, and to a lesser extent laboratory data, are also accumulating copies of whatever information is flowing through their systems in electronic format.
• Health Information Organizations – A special case of the clearinghouse model, these entities are mostly concerned with facilitating communications among regional health care providers, and in some cases are also undertaking data analysis services on behalf of their clients. As such, these organizations in many instances accumulate some portions of medical records data for some segments of the population in their geographical catchment areas.
• Technology Vendors – Those who supply electronic means to health data creators, and particularly the vendors who offer their technology in a remote service model, retain full access to their customers data, and for smaller customers, such as physicians in private practice, technology vendors are contractually reserving rights to make use of health data in a manner consistent with HIPAA regulations.
• Consumers – Aside from the emerging personal health monitoring devices and applications, a small minority of savvy consumers is also maintaining personal health records separately from their medical services providers, usually in remotely stored and web accessible repositories.

Meaningful Health Information Exchange
While Meaningful Use Stage 1 did not introduce any tangible breakthroughs in health information exchange beyond what was already occurring, the proposed Stage 2 measures are attempting to spur exchange of health data in several ways.

• Increase of exiting exchange – All thresholds for information exchange already in place, such as prescription data and laboratory results data, have been increased.
• Public Health Reporting – Actual reporting of data to government agencies is now required.
• Provider-to-provider – Some ad-hoc, point-to-point, standardized exchange of clinical summaries between various health care providers will be required.
• Provider-to/from-patient – In addition to requiring that physicians and hospitals provide health information to patients in electronic format, Meaningful Use Stage 2 places requirements on patients to contact their doctors by email and to access their electronic medical records online. The proposed rules stop short of mandating that patients actually copy their medical records themselves, or ship a copy to a third party recipient, but we have Stage 3 and onwards to look forward to. Either way, technology must be enabled to allow patients, or authorized entities (family, friends, other software, etc.) to extract copies of health information from the HIPAA covered entities where the data was created.

So where is the Big Data of health care? It is very likely that Meaningful Use Stage 2, along with accelerated Electronic Health Records adoption, will increase the size and number of current health data repositories, as well as the ad-hoc exchange of information between them. Changes in reimbursement models will also spur the slicing and dicing of health data, particularly for the purpose of risk management, but there is nothing in the proposed Meaningful Use Stage 2 rules to suggest wholesale merging of health data repositories, and on their own, none of them could be considered Big Data. What if we endeavor to index the contents of all repositories, per the PCAST model, and allow government, or other legitimate “stakeholders”, access to query every indexed and networked health data repository in the land? Is this the much touted and feverishly anticipated Big Data of health care? Meh… Something is still missing.

Big Data is not just lots and lots of data. Big Data is indeed big, but it is also very difficult to accommodate in traditional relational database systems. Big Data is very dynamic and changes fast, furiously and continuously, and Big Data is usually a combination of multiple unrelated sources; it is messy, inaccurate and needs lots of cleaning, processing and culling before it can be used. Well, we all know health care data is a royal mess, but other than that it has no other characteristics of Big Data. Some forward thinking clinical researchers, concerned with the ability of “decision makers” to make decisions for us, are suggesting that we make the data bigger by adding patient reported “psychosocial issues and health behavior”, which are usually outside the realm of medical care. They boldly envision doctors administering questionnaires to their patients to enrich the data sets obtainable by tying together “millions of encounters in real-world settings”. Not sure how you do that over disparate repositories without fully identifying each patient, but those are just details, and surely patients will see the value in allowing decision makers to assess our quality of life for comparative-effectiveness purposes. Anyway, adding some very patient-centered fields, quantifying your happiness or sadness, to the medical record is not going to elevate health care data to the status of Big Data. In order for health care data to become truly Big Data, it will have to be combined with other data sources, such as social media data, Internet search data, financial data, census data, shopping data, cell phone data, and the list goes on. And herein lies the Big excitement.

Of course, once we throw health care data into the boiling cauldron of Big Data, many wondrous things can emerge along with some nightmarish ones too. The only (legal) tool for extracting health care data from the HIPAA covered ecosystem today is the patient, because the patient is the only one who can legally “transmit” data from a covered entity to one that is not hampered by such details, like the various standalone Personal Health Records provided by private companies and all sorts of other health and wellness tools built by eager entrepreneurs. Once those shiny new “Transmit” buttons are added to patient portals, per Meaningful Use Stage 2 rules, there will no doubt be dozens of tools competing for “informed permission” from patients to crawl health care providers’ portals and auto extract everything possible and aggregate it “on behalf” of the patient. Will patients cooperate and donate personal health records to the Big Data enterprise? Perhaps a few, but not enough to make the bells ring. There will need to be a few more rounds of rulemaking before patient data can be truly liberated from those antiquated HIPAA protections, and properly used to build a few fortunes and to improve the quality and accuracy of the coupons we receive in the mail.

Parsimonious

I love persimmons with their luscious flavor and their rich exotic texture, but parsimony has nothing to do with persimmons. For the 99% of Americans who are less familiar with the term parsimonious than they are with the rare persimmon fruit, here are the suggested synonyms to parsimonious, according to the Merriam Webster dictionary: “cheap, chintzy, close, closefisted, mean, mingy, miserly, niggard, niggardly, stingy, penny-pinching, penurious, pinching, pinchpenny, spare, sparing, stinting, tight, tightfisted, uncharitable, ungenerous”.

In the sixth edition of its Ethics Manual, the American College of Physicians (ACP) is stating the following: “Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available” [emphasis added]. If you don’t use the term parsimonious in casual conversation, feel free to substitute any of the Merriam Webster synonyms, so you can enjoy the full flavor of this recommendation. We should note that the President of the ACP, Dr. Virginia Hood, while acknowledging that “it has some connotations where people think frugality or being parsimonious is the same as being mean or inadequate”, she does not “think that is the real meaning of that word". According to Dr. Hood “Parsimonious is a good word in the sense that it means that you use only what's necessary". Unfortunately she stopped short of defining “necessary”.

But the term parsimonious can be understood in a different way too. From the Latin “lex parsimoniae”, parsimonious, when scientifically understood could be a reference to Occam’s razor principle “requiring that the simplest of competing theories be preferred to the more complex or that explanations of unknown phenomena be sought first in terms of known quantities”. So perhaps the ACP is advising doctors to refrain from seeking zebras each time they hear galloping hooves, which may be fine medical advice up to the point where it requires respectful consideration for “resources”, which is just a polite term for money. When money is inserted into the scientific equation, we are drawn back to the penny-pinching definition, and since nobody wants to go on record advocating cheap care, we are back to parsimonious and the comfortable ambiguity cover it provides.

As noted in a recent New York Times article, despite this ambiguity, and perhaps precisely because of it, parsimonious care is quickly becoming a very popular term in the industry. In a NEJM article on costs of health care, Peter J. Neumann dares to ask the question and proceeds to answer it too: “Is “parsimonious” the right word? Perhaps there are better ones, but “frugal,” “prudent,” “thrifty,” “cost-conscious,” and others would also raise objections. … Calling it parsimonious is a reasonable start.” Yes, we can’t really call it what it is because it would raise objections. Similarly, we can’t call something a “tax” because it would raise objections, so we call it “penalty” instead, and this too is a reasonable start.

So what does parsimonious care look like? There are no exact descriptions, presumably because they too would raise “objections”, but there are philosophical principles involved. Dr. Zeke Emanuel, for example, is thrilled with the ACP daring to be “a professional society unafraid of advocating the principle of cost-effectiveness”. Cost-effectiveness, which has been in wide use before parsimonious came into vogue, is best examined at the edges where costs differ widely and effectiveness is held constant, or vice versa. It is prudent to stay away from instances where both costs and effectiveness vary widely in direct proportion to each other, because close scrutiny may raise objections. Perhaps this is where parsimonious care kicks in, invoking the renowned 80-20 business rule. If you get injured in an accident and we can restore you to 80% functionality for 20% of the cost, should we really spend the remainder 80% of the money for a measly 20% in diminishing returns to society? 

We may be able to gain additional insight by understanding what parsimonious care is not. A much debated recent study published in Health Affairs concludes that for office-based physicians, electronic access to imaging and lab results does not reduce the frequency of test orders, and advises that “[i]nsurers and health care providers should also be wary of claims that computerization alone will lead to a more parsimonious practice style”. Disregarding the policy implications and the validity of these conclusions, along with the vigorous rebuttals, and sticking with our largely semantic analysis, we may conclude that a reduction in ordering of expensive tests is a characteristic of parsimonious care. Examining the data in this study, which has not been questioned by those taking issue with the conclusions, one should be immediately struck by the fact that doctors in private solo practice are about four times less likely to order expensive imaging tests than physicians employed by hospitals, and significantly less likely to do so than doctors practicing in large group settings.

Since this particular study took the liberty of making some pretty wild assumptions, and since the rebuttals engaged in similarly wild predictions, perhaps it would be beneficial to disregard the multitude of controversial trees and observe the forest in plain view, which reveals that parsimonious care is more likely to be delivered in small private practice. The obligatory implications to policy makers would be to quit the mindless herding of doctors into unparsimonious hospital employment and consolidation, and to conduct some studies of readily available data on the parsimony, or cheapness, of care in various practice settings. The definition of parsimonious care, at least for ambulatory practice, as that which is offered in small private practice settings, and the promotion of the same, is guaranteed to not raise any objections from the public. The alternative would be to continue using terminology nobody understands to make policy nobody understands, while engaging in esoteric conversations for the illuminati who possess the encryption keys to public discourse.

Addendum: For the sake of completeness, here is the brand new response from the authors of the Health Affairs study on imaging, to the ONC rebuttal. (3/12/2012)

Opportunity for HIT Vendors to Do Good

Yesterday, I found an email from Health and Human Services (HHS) in my inbox highlighting a new initiative where the “Obama Administration and Text4Baby join forces to connect pregnant women and children to health coverage and information”. The goal of this partnership is “to promote enrollment in both Medicaid and the Children’s Health Insurance Program (CHIP)”. Having more babies and children obtain insurance coverage is obviously a worthy endeavor, and if it can be accomplished by simply sending informative text messages to pregnant women, even better. Of course having insurance coverage doesn’t always translate into having access to an actual doctor, particularly for Medicaid enrollees.

In an unrelated coincidental turn of events, it just so happened that I have had the recent opportunity to spend time with large numbers of Pediatric practices, most of which were small independent practices in middle-class suburban areas. The main goal of these conversations was to elicit doctors’ opinions on Electronic Health Records (EHR). As expected, only a small fraction of independent Pediatricians are currently using fully certified EHRs, and amongst those there is an even distribution of happy customers and disillusioned ones. A significant portion is actively engaged in purchasing EHRs, but the vast majority is pondering on what to do next. It turns out that one cannot have any discussions about EHR without sooner or later digressing to costs and precarious financial situations. Yes, EHR usability, or lack thereof, comes up in casual conversation, but by far most doctors understand that paper is over and computers are here to stay whether they are perfect or not. The barrier to jumping on the EHR bandwagon is always financial. Pediatrics in particular is not a very lucrative specialty and cash reserves are practically nonexistent in these small practices. 

And here is where I observed a very interesting and very positive trend. These suburban practices are considering opening their doors to Medicaid kids in larger and larger numbers. Both the recession and the possibility of obtaining enough government incentives to cover technology purchases are responsible for this trend, which I observed locally, but may very well be larger in scope. Pediatricians (and pediatric sub-specialists) are only eligible for Medicaid incentives and only eligible for the full incentive if at least 30% of their patients are covered by Medicaid. Meaningful Use incentives were aimed at providing a partial solution to the cost conundrum, of course, but there is a chicken and egg dilemma here. You can’t get the incentives unless you buy the EHR and you can’t buy the EHR unless you get the incentives, or take a loan, which is a very frightening alternative for most small practices and for many independent physicians whose personal wealth has been decimated in the last few years.

For illustration purposes, the total first year cost of an average EHR purchase, including training, implementation and hardware is around $100,000 for a practice of 5 physicians. Medicaid first year incentives for such a practice would almost to the penny cover the initial EHR costs. More importantly, Medicaid first year incentives are based on the administrative activities of buying the EHR and NOT on achievement of Meaningful Use. It doesn’t make sense to ask Medicaid to advance doctors $100,000 based on a promise to buy an EHR, and it would be unwise to have Medicaid send incentive checks to EHR vendors, but there is a third option, which provides EHR vendors with an opportunity to do well by doing good, for a change.

Here is how I would structure this transaction:

• EHR vendor in partnership with hardware vendor creates a bundled offering not to exceed the $21,000 per provider which is equal to the Medicaid first year incentive.
• Practice submits proof of eligibility for Medicaid maximum incentive to vendor
• Practice submits proof of registration with CMS and State Medicaid program
• Practice contractually obligates itself to attest to State Medicaid and submit proof of attestation to vendor within an agreed upon timeframe from contract signing (10 working days should be fine)
• Practice contractually obligates itself to remit full payment to vendor upon receipt of Medicaid incentives and no later than 6 months from contract signing

The value proposition to EHR (and hardware) vendors should be obvious considering that most of those who had the cash, already bought an EHR and the bulk of the remaining market is going to take its sweet good old time to “make a decision”. I do understand the implications of such arrangements to cash flow and balance sheets of technology vendors, but the competitive advantage to those larger vendors who can afford to make this offer would be big enough to warrant the costs, and the risk to the vendor is truly minimal. Yes, this would be similar to extending credit to the practice for six months, but psychologically this is very different, since there is much unwarranted mistrust amongst physicians that Medicaid will actually send them a check. Seeing that the vendor is willing to participate in taking the “risk” will generate significant and quantifiable good will.

The value proposition for society and the moms reached by Text4Baby is that the brand new coverage they are obtaining will actually come with a doctor happy to take care of their babies. Priceless.